Path Dependency and the Politics of Socialized Health Care

David Brady is professor in the School of Public Policy at the University of California, Riverside. He is also director of the Blum Initiative on Global and Regional Poverty. From 2012 to 2015, he was director of the Inequality and Social Policy Department at the WZB Berlin Social Science Center. He studies poverty/inequality, social policy, political economy, and health/health care, among other topics. He is the author of Rich Democracies, Poor People, and coeditor of The Oxford Handbook of the Social Science of Poverty.

Susanne Marquardt is a research fellow at the WZB Berlin Social Science Center. Her research focuses on comparative welfare state policies, housing, and inequality. Currently, she is pursuing her PhD on the effects of changes in home ownership on welfare states. She is also a research assistant in a collaborative project with the Institute for Public Policy Research (IPPR) in London and Aston University in Birmingham which compares housing policies in Germany and the UK.

Gordon Gauchat is assistant professor of sociology at the University of Wisconsin–Milwaukee. His research focuses on the interaction of public perceptions of science and political and cultural cleavages in the United States and Europe. He has published research in American Sociological Review, Social Forces, Gender and Society and Public Understanding of Science. His current work examines public perceptions of medical doctors' and climate scientists' legitimacy to influence political policy.

Megan M. Reynolds is assistant professor in the Department of Sociology at the University of Utah. Her work examines health and health inequalities in order to understand processes of stratification and their consequences. She is particularly interested in the role of power and politics in influencing population health and in how gender and ethnicity condition the health of various immigrant groups. She has published work in Social Forces, the Journal of Health and Social Behavior, and Gender in Management. She holds an MA in applied sociology from the University of Massachusetts Boston and a PhD in sociology from Duke University.

Abstract

Rich democracies exhibit vast cross-national and historical variation in the socialization of health care. Yet, cross-national analyses remain relatively rare in the health policy literature, and health care remains relatively neglected in the welfare state literature. We analyze pooled time series models of the public share of total health spending for eighteen rich democracies from 1960 to 2010. Building on path dependency theory, we present a strategy for modeling the relationship between the initial 1960 public share and the current public share. We also examine two contrasting accounts for how the 1960 public share interacts with conventional welfare state predictors: the self-reinforcing hypothesis expecting positive feedbacks and the counteracting hypothesis expecting negative feedbacks. We demonstrate that most of the variation from 1960 to 2010 in the public share can be explained by a country's initial value in 1960. This 1960 value has a large significant effect in models of 1961–2010, and including the 1960 value alters the coefficients of conventional welfare state predictors. To investigate the mechanism whereby prior social policy influences public opinion about current social policy, we use the 2006 International Social Survey Programme (ISSP). This analysis confirms that the 1960 values predict individual preferences for government spending on health. Returning to the pooled time series, we demonstrate that the 1960 values interact significantly with several conventional welfare state predictors. Some interactions support the self-reinforcing hypothesis, while others support the counteracting hypothesis. Ultimately, this study illustrates how historical legacies of social policy exert substantial influence on the subsequent politics of social policy.